- Paperback: 288 pages
- Publisher: Picador; 1st edition (January 22, 2008)
- Language: English
- ISBN-10: 0312427654
- ISBN-13: 978-0312427658
- Product Dimensions: 5.9 x 0.8 x 8.2 inches
- Shipping Weight: 9.6 ounces (View shipping rates and policies)
- Average Customer Review: 4.7 out of 5 stars See all reviews (373 customer reviews)
- Amazon Best Sellers Rank: #3,555 in Books (See Top 100 in Books)
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Better: A Surgeon's Notes on Performance 1st Edition
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From Publishers Weekly
Starred Review. Surgeon and MacArthur fellow Gawande applies his gift for dulcet prose to medical and ethical dilemmas in this collection of 12 original and previously published essays adapted from the New England Journal of Medicine and the New Yorker. If his 2002 collection, Complications, addressed the unfathomable intractability of the body, this is largely about how we erect barriers to seamless and thorough care. Doctors know they should wash their hands more often to avoid bacterial transfer in the ward, but once a minute does seem extreme. Using chaperones for breast exams seems a fine idea, but it does make situations awkward. "The social dimension turns out to be as essential as the scientific," Gawande writes—a conclusion that could serve as a thumbnail summary of his entire output. The heart of the book are the chapters "What Doctors Owe," about the U.S.'s blinkered malpractice system, and "Piecework," about what doctors earn. Cheerier, paradoxically, are the chapters involving polio and cystic fibrosis, featuring Dr. Pankaj Bhatnagar and Dr. Warren Warwick, two remarkable men who have been able to catapult their humanity into their work rather than constantly stumble over it. Indeed, one suspects that once we cure the ills of the health care system, we'll look back and see that Gawande's writings were part of the story. (Apr.)
Copyright © Reed Business Information, a division of Reed Elsevier Inc. All rights reserved. --This text refers to an out of print or unavailable edition of this title.
From Bookmarks Magazine
A surgeon at the Brigham and Women's Hospital in Boston and an assistant professor at the Harvard School of Public Health, Dr. Atul Gawande succeeds in putting a human face on controversial topics like malpractice and global disparities in medical care, while taking an unflinching look at his own failings as a doctor. Critics appreciated his candor, his sly sense of humor, and his skill in examining difficult issues from many perspectives. He conveys his messagethat doctors are only human and therefore must always be diligent and resourceful in fulfilling their dutiesin clear, confident prose. Most critics' only complaint was that half of the essays are reprints of earlier articles. Gawande's arguments, by turns inspiring and unsettling, may cause you to see your own doctor in a whole new light.
Copyright © 2004 Phillips & Nelson Media, Inc. --This text refers to an out of print or unavailable edition of this title.
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Top Customer Reviews
The most moving and thought-provoking of these essays, to me, was "The Doctors of the Death Chamber," in which Gawande interviews four doctors (whom he labels "A," "B," "C" and -- wait for it -- "D," in order to secure their anonymity) who help states carry out the death penalty humanely. The use of "humanely" here is questionable; it's humane in the sense that, if we are to use the death penalty, we must not be needlessly cruel at the time of the criminal's death. But it's inhumane in the larger sense that we are furthering a corrupt system -- we are "tinker[ing] with the machinery of death," to use Justice Blackmun's words. Since a doctor's role is to protect human lives, are anaesthesiologists who help execute people painlessly violating their roles? To put it more succinctly: should a doctor make the best of the machinery of death, or should he take no part in the machine? The American Medical Association has its answer and its role. Democratically elected governments have their own. It's Gawande's job to teach us that easy answers don't exist for complicated problems like this.
One reason it's so easy to come up with easy answers for questions like this is that we rarely come face to face with the system we critique. Gawande does the legwork for us. He's at his best, in this regard, when he interviews a medical-malpractice attorney, a doctor, and the family of a dead patient involved in one malpractice case. We're all inclined to boo at the malpractice attorney . . . right up to the moment we feel we've been wronged, when that attorney is the man we want on our side. Gawande knows that this is how we work, so he takes some time to look at a case when doctors failed other doctors: Gawande's friend Bill Franklin found that doctors had failed to treat a tumor on Franklin's son that they should have noticed years before -- that someone had actually singled out on an X-ray for further study. This is the test case where ethics hits the road: when it's your own son, and you're a doctor, and you're well aware of the expenses of medical malpractice, what do you do? After trying other routes, Franklin did what so many others do: he sued and won. (Along the way Franklin helped establish a precedent in the Massachusetts Supreme Court, in the case of Franklin v. Massachusetts General Hospital et al., affecting the statute of limitations on malpractice cases. Seems worth reading.)
Better contains lots of great little insights into the medical profession -- for instance, how difficult it is to get doctors and nurses to wash their hands as often as is safe for patients, or the awkwardness of a male doctor palpating a naked female patient. Throughout it all, Gawande's organizing principle is to lay out for us the system in which doctors work, the limitations they operate under, and how they make the best within those limitations.
I'm less inclined than I used to be to believe that Gawande has an agenda, but I do think that a slightly different arrangement of the chapters within Better would have sent a different message. Had the chapter on malpractice come at the end of the book, after we've read about Gawande's own mistakes and about sloppy handwashing, we'd be less sympathetic toward doctors. In "The Score," which I've mentioned before, Gawande tells us that C-sections are vital in a world where doctors can't be expected to be very talented; in "The Bell Curve," he reveals that not all cystic-fibrosis clinics are the same, and that the medical industry was reluctant for years to release data on how well individual clinics performed. With these insights in mind, malpractice would seem to the reader to be completely justified. As it is, the malpractice article is tucked into the middle of the book; Better ends with a story about heroically performing surgery in poor rural India, and with a few pieces of advice to newly-minted doctors. It's a hopeful ending. I can't decide whether this arrangement was deliberately obfuscating. Nor does Gawande spend much time explaining whether malpractice makes doctors better.
He's fair throughout, however, and his point is that doctors' work is hard. Understanding precisely why it's hard, and what they do to get their jobs done under trying conditions, is Better's job, and it succeeds admirably. It's a great, thought-provoking, fun read.
In a section of his book, entitled "The Mop-Up," Gawande discusses polio and the campaign to wipe it out in Asia wherein he was a momentary observer in the field in 2003. Way back in ancient history, when I was a mere child in the 1940s and America was hit with a polio epidemic, I was diagnosed with polio and almost died. Hence the relevance here for me. But more than that, I am convinced to this day that I was "saved" because of the efforts of a nurse -- I'm sure she was one of Gawande's "positive deviants" which he describes in his book -- who insisted on treating me and others with a controversial treatment (opposed by most of the medical "establishment" at the time) called "The Sister Kenny Method." She never lost a patient, by the way; we all recovered without any significant aftereffects that I know of.
Fortunately, from that time in the 1940s I never needed to be hospitalized again. That is, until 2002. Then I had a heart attack and was forced into a hospital for an angioplasty and had to take note of medical matters, including the state of medical care in this country." So, whereas before that latter year I could ignore books of the type that Gawande writes, I now have a profound interest in all things medical. Even more so since my second heart attack and angioplasty in 2006. (I even subscribe to daily updates via e-mail about medical topics!) I am now very concerned about "better" when it comes to medical care and policy.
Gawande divides his book into three significant sections: Diligence, Doing Right, and Ingenuity. He says that "Diligence" is "the necessity of giving sufficient attention to detail to avoid error and prevail against obstacles." The section "Doing Right" considers topics such as "how much doctors should be paid, and what we owe patients when we make mistakes." Important as these sections are, the final section, "Ingenuity," is of even greater importance in my opinion. Ingenuity, he says, "demands more than anything a willingness to recognize failure" and "arises from deliberate, even obsessive, reflection on failure and a constant searching for new solutions." Amen to that!
Furthermore, Gawande quite realistically concludes: "Betterment is a perpetual labor. The world is chaotic, disorganized, and vexing, and medicine is nowhere spared that reality. To complicate matters, we in medicine are also only human ourselves. ...Yet...to live as a doctor is to live so that one's life is bound up in others' and in science and in the messy, complicated connection between the two. It is to live a life of responsibility. The question...is not whether one accepts the responsibility. Just by doing this work one has. The question is, having accepted the responsibility, how one does such work well." Well said, that. Couldn't agree more.
One of the more politically relevant issues (at least for me) that Gawande discusses is the matter of medical practitioners' involvement in executions. In his essay, "The Doctors of the Death Chamber," he says that "We [doctors and nurses] must do our best to choose intelligently and wisely," and then notes that "Sometimes, however, we will be wrong -- as I think the doctors and nurses are who have used their privileged skills to make possible 876 deaths by lethal injection thus far." I cannot understand how a physician -- "First, do no harm" -- could even contemplate participating in the killing of another human being, even if officially sanctioned. Gawande addresses this issue in what I think is a sensible manner. But the debate on this issue is current, lively and will continue for some time.
I do, however, wish that Gawande had spent more time discussing the future of health care in America as regards the delivery of medical services to all its citizens. He briefly touches on this matter, but not in detail. From my perspective, HMOs are definitely not the solution (they are part of the current problem!) and government-managed health care (socialized medicine) is even less desirable. I mean, the government, in my opinion, cannot even provide a decent public education for our children; how can we expect it to provide decent health care? I have considered a number of proposals, all of them wanting in some way or other. I'd like to see Gawande tackle this problem in a detailed way from a physician's perspective. Maybe another book?
Moreover, regarding the above, it is disturbing to read what one American medical reviewer recently stated: "We spend 50 percent more per capita on health care than any other country, for a total of $2 trillion a year, yet our health system, according to the World Health Organization, ranks 37th worldwide. ...By any measure -- longevity, infant mortality, burden of disease -- we sit in the basement of the industrialized world." For a country that can spend trillions of dollars to wage war and promote "regime changes" throughout the world, that statement is embarrassing and hard to fathom.
All in all, "Better" is a good read and extremely informative. It is full of interesting anecdotes, as well as confronting, if only briefly, some of the major issues in the practice of medicine today such as the influence of money in the healthcare system, the problem of malpractice lawsuits, and medical practice under the tensions of the military battlefield, as well as more mundane issues which are often ignored such as the simple act of hand washing or how nakedness impacts the examination room. Since I have had my own experiences lately with the medical establishment, I can now relate to at least some of the topics that Gawande discusses. Therefore -- and since there is no medical experience like a really personal one -- I highly recommend this book to all readers. I guarantee you'll learn a lot, you'll enjoy the fine writing, and you'll have some thinking to do about the state of medical care in America.